1932267887 NPI number — DR. INGRID MARY DIEDEREN PH D

Table of content: DR. INGRID MARY DIEDEREN PH D (NPI 1932267887)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1932267887 NPI number — DR. INGRID MARY DIEDEREN PH D

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
DIEDEREN
Provider First Name:
INGRID
Provider Middle Name:
MARY
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
PH D
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1932267887
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/08/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
172 ASHELAND AVENUE
Provider Second Line Business Mailing Address:
SUITE D
Provider Business Mailing Address City Name:
ASHEVILLE
Provider Business Mailing Address State Name:
NC
Provider Business Mailing Address Postal Code:
28801
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
828-253-1445
Provider Business Mailing Address Fax Number:
828-253-1456

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
172 ASHELAND AVENUE
Provider Second Line Business Practice Location Address:
SUITE D
Provider Business Practice Location Address City Name:
ASHEVILLE
Provider Business Practice Location Address State Name:
NC
Provider Business Practice Location Address Postal Code:
28801
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
828-253-1445
Provider Business Practice Location Address Fax Number:
828-253-1456
Provider Enumeration Date:
12/04/2006

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 103TC0700X , with the licence number:  1376 , registered in the state of NC ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 0324H . This is a "BCBS" identifier . This identifiers is of the category "OTHER".




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